Factores asociados a infecciones serias en pacientes hospitalizados con lupus eritematoso sistémico / Factors associated with serious infections in patients hospitalized with systemic lupus erythematosus

RESUMEN Introducción. En pacientes con lupus eritematoso sistémico (LES) existe incremento de infecciones debido a la propia enfermedad, al uso de inmunosupresores y corticoides. Objetivo. Identificar los factores asociados a infecciones serias en pacientes lúpicos en un hospital de referencia nacional. Estudio retrospectivo, analítico, de casos y controles en el Servicio de Reumatología del Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú. Métodos. Se analizó el registro de pacientes hospitalizados en el periodo de estudio, los casos fueron pacientes en los que se demostró la etiología de la primera infección durante su hospitalización. Los controles fueron pacientes lúpicos hospitalizados sin infecciones en el mismo periodo de estudio. Se analizaron variables asociadas al desarrollo de infecciones. Resultados. 61 pacientes de 390 hospitalizados desarrollaron infecciones durante su hospitalización. 48 desarrollaron 1 solo evento infeccioso (en 40 se demostró etiología). Los casos tuvieron mayor actividad, daño y comorbilidad en comparación con los controles. En el análisis univariado, el salario (p=0,031), el uso de inmunosupresores a la admisión (previo: p=0,004 y actual: p=0,004), el uso de glucocorticoides (<30 días: p=0,015 y >30-360 días: p=0,028), la actividad (p=0,029) y el daño (p=0,026) producido por la enfermedad, y el tiempo de hospitalización (p=0,045) tuvieron asociación estadísticamente significativa. En el análisis multivariado, los días de hospitalización se asociaron al desarrollo de infecciones. Conclusiones. Existió asociación entre días de hospitalización y el desarrollo de infecciones serias en pacientes lúpicos durante el periodo de estudio.

ABSTRACT Introduction. Lupus patients have an increased risk of developing infections due to the disease, use of immunosuppressants and corticosteroids. Objective. To identify the associated factors for serious infections in lupus patients in a national referral hospital. Retrospective, analytical, case-control study in the Rheumatology Service of the Guillermo Almenara Irigoyen National Hospital, Lima, Peru. Methods. The registry of hospitalized patients in the study period was analyzed, the cases were patients in whom the etiology of the first infection developed their hospitalization. Controls were hospitalized lupus patients without infections in the same study period. Variables predisposing to the development of infections were analyzed. Results. 61 patients out of 390 hospitalized developed infections during their hospitalization. 48 developed 1 only infectious event (in 40 an etiology developed). The cases had higher damage, activity and comorbidity compared to the controls. In the univariate analysis, salary (p = 0.031), use of immunosuppressants upon admission (previous: p = 0.004 and current: p = 0.004), use of glucocorticoids (<30 days: p = 0.015 and> 30-360 days: p = 0.028), activity (p = 0.029) and damage (p = 0.026) produced by the disease and length of hospitalization (p = 0.045), had a statistically significant association. In the multivariate analysis, the days of hospitalization were associated with the development of infections. Conclusions. There is an association between days of hospitalization and the development of serious infections in lupus patients in the study period.

Clinical features, damage accrual, and survival in patients with familial systemic lupus erythematosus: data from a multi-ethnic, multinational Latin American lupus cohort.

OBJECTIVES: This study aimed to compare the clinical features, damage accrual, and survival of patients with familial and sporadic systemic lupus erythematosus (SLE). METHODS: A multi-ethnic, multinational Latin American SLE cohort was studied. Familial lupus was defined as patients with a first-degree SLE relative; these relatives were interviewed in person or by telephone. Clinical variables, disease activity, damage, and mortality were compared. Odds ratios (OR) and 95% confidence intervals (CI) were estimated. Hazard ratios (HR) were calculated using Cox proportional hazard adjusted for potential confounders for time to damage and mortality. RESULTS: A total of 66 (5.6%) patients had familial lupus, and 1110 (94.4%) had sporadic lupus. Both groups were predominantly female, of comparable age, and of similar ethnic distribution. Discoid lupus (OR = 1.97; 95% CI 1.08-3.60) and neurologic disorder (OR = 1.65; 95% CI 1.00-2.73) were significantly associated with familial SLE; pericarditis was negatively associated (OR = 0.35; 95% CI 0.14-0.87). The SLE Disease Activity Index and Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) were similar in both groups, although the neuropsychiatric (45.4% vs. 33.5%; p = 0.04) and musculoskeletal (6.1% vs. 1.9%; p = 0.02) domains of the SDI were more frequent in familial lupus. They were not retained in the Cox models (by domains). Familial lupus was not significantly associated with damage accrual (HR = 0.69; 95% CI 0.30-1.55) or mortality (HR = 1.23; 95% CI 0.26-4.81). CONCLUSION: Familial SLE is not characterized by a more severe form of disease than sporadic lupus. We also observed that familial SLE has a higher frequency of discoid lupus and neurologic manifestations and a lower frequency of pericarditis.

[20 years urethroplasty experience. Retrospective review and outcomes.] / 20 años realizando uretroplastias. Revisión retrospectiva y resultados.

OBJECTIVE: To present the evolution in the diagnosis and treatment of urethral stricture, after performing 300 surgical procedures over urethral meatus,penile and bulbar urethra along 20 years, contrasting two surgical periods: from 1997-2006 to 2007-2016. MATERIAL AND METHODS: A retrospective review of495 medical records between 1997-2016 was conducted.All the patients treated with urethroplasty were included and those who under went internal urethrotomy,stents or dilatations plus those with strictures due to prostate cancer treatment or orthotopic neobladder were excluded. RESULTS: 300 patients were selected: 100 patients within the first period (1997-2006) and 200 within the second (2007-2016). The median follow-up was 36 months (range 12-60). In relation to the surgical techniques, among the most employed, four are outstanding so their results can be compared in both periods:termino-terminal urethroplasty, penile flap urethroplasty and the buccal mucosa in penile or bulbar urethroplasty.Other techniques were incorporated during the second period. The best outcomes were provided by end' to endurethroplasty with 90 and 92% success. Over the second period, buccal mucosa indications were consolidated with an increase use from 16% to 56%. Were considered as successful those patients that did not need any endoscopic procedure and reporting excellent urinary flow without low urinary tract symptoms. CONCLUSIONS: A trend towards an increased usage of open surgery vs urethrotomy is observed. Buccal mucosa graft has been consolidated as a reconstructive technique. End-to end urethroplasty seems to provide the best functional outcomes.

OBJETIVO: Mostrar la evolución en el diagnóstico y tratamiento de la estenosis uretral tras realizar 300 procedimientos quirúrgicos sobre meato uretral, uretra peneana y bulbar a lo largo de veinte años, comparando dos períodos: 1997-2006 y 2007-2016. MATERIAL Y METODOS: Llevamos a cabo una revisión de los historiales de 495 pacientes diagnosticados de estenosis de uretra entre 1997 y 2016. Incluímos todos aquellos que fueron sometidos a algún tipo de uretroplastia y fueron excluidos los tratados mediante uretrotomía interna, stents, dilataciones, y aquellos que presentaban estenosis a nivel de anastomosis, secundarias a tratamiento del cáncer de próstata o realización de vejigas ortotópicas. RESULTADOS: Seleccionamos 300 pacientes, 100 en el primer período (1997-2006) y 200 en el segundo (2007-2016). La media de seguimiento fue de 36 meses (12-60). Entre las técnicas empleadas destacamos cuatro de ellas para comparar los resultados en ambos períodos: Uretroplastia término terminal, Uretroplastia con mucosa oral en uretra peneana y bulbar y Uretroplastia con colgajo en uretra peneana. En el grupo 1,de 100 pacientes obtuvimos buenos resultados en el 83% y en el grupo 2, de 200 pacientes en el 81%.La técnica que mejores resultados proporcionó fue la término terminal con un 90 y 92% respectivamente. Enel segundo período se consolidó el uso de mucosa oral pasando de utilizarla en un 16% de los casos a un 56%. Consideramos buen resultado funcional aquellos pacientes que no precisaron ningún tipo de manipulación endoscópica o quirúrgica y manifestaron confort miccional con ausencia de síntomas obstructivos o irritativos. CONCLUSIONES: Aumenta el número de pacientes con estenosis de uretra tratados mediante cirugía abierta frente a la uretrotomía. Se consolida el empleo de la mucosa oral en todas sus variantes y se confirma que la uretroplastia término terminal es la técnica que proporciona mejores resultados.

20 años realizando uretroplastias. Revisión retrospectiva y resultados / 20 years urethroplasty experience. Retrospective review and outcomes

OBJETIVO: Mostrar la evolución en el diagnóstico y tratamiento de la estenosis uretral tras realizar 300 procedimientos quirúrgicos sobre meato uretral, uretra peneana y bulbar a lo largo de veinte años, comparando dos períodos: 1997-2006 y 2007-2016. MATERIAL Y METODOS: Llevamos a cabo una revisión de los historiales de 495 pacientes diagnosticados de estenosis de uretra entre 1997 y 2016. Incluímos todos aquellos que fueron sometidos a algún tipo de uretroplastia y fueron excluidos los tratados mediante uretrotomía interna, stents, dilataciones, y aquellos que presentaban estenosis a nivel de anastomosis, secundarias a tratamiento del cáncer de próstata o realización de vejigas ortotópicas. RESULTADOS: Seleccionamos 300 pacientes, 100 en el primer período (1997-2006) y 200 en el segundo (2007-2016). La media de seguimiento fue de 36 meses (12-60). Entre las técnicas empleadas destacamos cuatro de ellas para comparar los resultados en ambos períodos: Uretroplastia término terminal, Uretroplastia con mucosa oral en uretra peneana y bulbar y Uretroplastia con colgajo en uretra peneana. En el grupo 1, de 100 pacientes obtuvimos buenos resultados en el 83% y en el grupo 2, de 200 pacientes en el 81%.La técnica que mejores resultados proporcionó fue la término terminal con un 90 y 92% respectivamente. Enel segundo período se consolidó el uso de mucosa oral pasando de utilizarla en un 16% de los casos a un 56%. Consideramos buen resultado funcional aquellos pacientes que no precisaron ningún tipo de manipulación endoscópica o quirúrgica y manifestaron confort miccional con ausencia de síntomas obstructivos o irritativos. CONCLUSIONES: Aumenta el número de pacientes con estenosis de uretra tratados mediante cirugía abierta frente a la uretrotomía. Se consolida el empleo de la mucosa oral en todas sus variantes y se confirma que la uretroplastia término terminal es la técnica que proporciona mejores resultados

OBJECTIVE: To present the evolution in the diagnosis and treatment of urethral stricture, after performing 300 surgical procedures over urethral meatus,penile and bulbar urethra along 20 years, contrasting two surgical periods: from 1997-2006 to 2007-2016. MATERIAL AND METHODS: A retrospective review of495 medical records between 1997-2016 was conducted.All the patients treated with urethroplasty were included and those who under went internal urethrotomy,stents or dilatations plus those with strictures due to prostate cancer treatment or orthotopic neobladder were excluded. RESULTS: 300 patients were selected: 100 patients within the first period (1997-2006) and 200 within the second (2007-2016). The median follow-up was 36 months (range 12-60). In relation to the surgical techniques, among the most employed, four are outstanding so their results can be compared in both periods:termino-terminal urethroplasty, penile flap urethroplasty and the buccal mucosa in penile or bulbar urethroplasty.Other techniques were incorporated during the second period. The best outcomes were provided by end’ to endurethroplasty with 90 and 92% success. Over the second period, buccal mucosa indications were consolidated with an increase use from 16% to 56%. Were considered as successful those patients that did not need any endoscopic procedure and reporting excellent urinary flow without low urinary tract symptoms. CONCLUSIONS: A trend towards an increased usage of open surgery vs urethrotomy is observed. Buccal mucosa graft has been consolidated as a reconstructive technique. End-to end urethroplasty seems to provide the best functional outcomes

[Substitution urethroplasty. Long term follow up results in a group of 50 patients]. / Uretroplastia de sustitución. Resultados del seguimiento a largo plazo en un grupo de 50 pacientes.

OBJECTIVES: To assess the results of substitution urethroplasty after a long follow-up in a group of 50 patients. METHODS: We conducted a retrospective study of patients with diagnosis of urethral stricture treated by augmentation techniques in the period 1999-2009. We included patients with penile and bulbar urethral stricture and, penile skin or oral mucosa as substitute tissue type. Urethral strictures of the meatus or fossa navicularis and posterior urethra, and other endoscopic or surgical procedures were excluded from the study. RESULTS: Fifty patients were included. Penile skin was used in 26 cases and buccal mucosa in 24. The average follow-up was 108 months. Recurrence rate was 25% in the cases in which oral mucosa was used as substitute tissue and 30.7% in the penile skin group. Of the 14 cases with recurrence of the stricture, 13 (92%) did so in the first five years of follow-up. Only one case was a recurrent stricture after six years of surgery. CONCLUSIONS: The recurrence of the stricture after augmentation urethroplasty occurs, in the majority of cases, in the first five years. After this period of time recurrence is very rare. Oral mucosa showed better results as substitute tissue in the urethral stricture surgery.

Uretroplastia de sustitución. Resultados del seguimiento a largo plazo en un grupo de 50 pacientes / Substitution urethroplasty. Long term follow up results in a group of 50 patients

OBJETIVO: Evaluar el resultado de la uretroplastia de sustitución tras un largo seguimiento en un grupo de 50 pacientes. MÉTODOS: Realizamos un estudio retrospectivo de pacientes con diagnóstico de estenosis uretral, tratados mediante técnicas de ampliación en el período 1999-2009. Incluimos pacientes con estenosis de uretra peneana y bulbar y, como material de sustitución, piel peneana y mucosa bucal. Fueron excluidos del estudio las estenosis de meato o fosa navicular, estenosis de uretra posterior y cualquier otro procedimiento endoscópico o quirúrgico. RESULTADOS: Se incluyeron 50 pacientes de los que en 26 casos se utilizó piel peneana y en 24 mucosa bucal. La media de seguimiento fue de 108 meses. Recidivaron el 25% de los casos en que se utilizó mucosa bucal como material de sustitución y el 30,7% cuando se empleó piel peneana. De los 14 casos en que recidivó la estenosis, 13 (92%) lo hicieron en los primeros cinco años de seguimiento. Tan sólo en un caso se produjo una recidiva pasados seis años de la cirugía. CONCLUSIONES: La recidiva de la estenosis tras la cirugía de ampliación se produce, en la mayoría de los casos, en los primeros cinco años. Una vez pasado este periodo de tiempo es poco frecuente la reestenosis. La mucosa bucal ofrece mejores resultados como material de sustitución en la cirugía de la estenosis uretral

OBJECTIVES: To assess the results of substitution urethroplasty after a long follow-up in a group of 50 patients. METHODS: We conducted a retrospective study of patients with diagnosis of urethral stricture treated by augmentation techniques in the period 1999-2009. We included patients with penile and bulbar urethral stricture and, penile skin or oral mucosa as substitute tissue type. Urethral strictures of the meatus or fossa navicularis and posterior urethra, and other endoscopic or surgical procedures were excluded from the study. RESULTS: Fifty patients were included. Penile skin was used in 26 cases and buccal mucosa in 24. The average. follow-up was 108 months. Recurrence rate was 25% in the cases in which oral mucosa was used as substitute tissue and 30.7% in the penile skin group. Of the 14 cases with recurrence of the stricture, 13 (92%) did so in the first five years of follow-up. Only one case was a recurrent stricture after six years of surgery. CONCLUSIONS: The recurrence of the stricture after augmentation urethroplasty occurs, in the majority of cases, in the first five years. After this period of time recurrence is very rare. Oral mucosa showed better results as substitute tissue in the urethral stricture surgery

An outbreak of serogroup C (ST-11) meningococcal disease in Tijuana, Mexico.

BACKGROUND: Invasive meningococcal disease (IMD) has been reported to be endemic in children from Tijuana, Mexico and the risk of an outbreak was always a threat. OBJECTIVES: To describe all clinical, epidemiological and microbiological features of a meningococcal outbreak that occurred in Tijuana, Mexico. METHODS: All cases with IMD were admitted at different emergency departments within the city and diagnosed by culture and agglutination tests. Further restriction fragment length polymorphism pulse field gel electrophoresis (RFLP-PFGE) and multi locus sequence typing (MLST) were performed. All clinical and epidemiological characteristics and interventions were evaluated, as well as risk factors associated with mortality. RESULTS: From 30 January 2013 to 30 March 2013 there were 19 cases of IMD all caused by Neisseria meningitidis serogroup C. The median age was 16 years (2-47), with higher frequency among individuals at least 13 years old (73.7%). At admission, meningitis was the main clinical presentation (94.7%), followed by purpura (78.9%), septic shock (42.1%) and disseminated intravascular coagulation (DIC, 36.8%). Overall mortality was seven (36.8%). Variables associated with higher mortality were, at admission, presence of septic shock, DIC and thrombocytopenia less than 70,000. All 19 cases had no identifiable site or cluster as the source of the outbreak. RFLP-PFGE showed a discriminatory power for only one profile on all N. meningitidis strains analyzed and a clone ST-11 was identified in all strains. Public health interventions were continuous case reporting of all suspected cases of IMD, an increase in active surveillance in all hospitals, training of medical and laboratory personnel, massive and rapid chemoprophylaxis to all close contacts as indicated, and promotion of good health habits. CONCLUSIONS: An outbreak with high mortality of IMD occurred in Tijuana, Mexico. This event and evidence of endemicity should encourage health authorities to evaluate meningococcal vaccination in the region.

Cáncer de mama: metástasis en ovario y colon / Breast cancer: Ovarian and colonic metastasis

Presentamos un caso de cáncer de mama en estadio ii que recidivó a nivel local a los 4 años, a nivel ovárico 6 años más tarde y en colon 13 años después. La paciente recibió tratamiento adyuvante quimioterápico tras el diagnóstico inicial de cáncer mama. Posteriormente, el tratamiento de las recidivas siempre fue la cirugía y la hormonoterapia adyuvante. Destaca la supervivencia libre de enfermedad de la paciente tras la recidiva ovárica

We present a case of stage II breast cancer that relapsed first in the surgical scar at 4 years after surgery, and then in the ovaries at 6 years and finally in the colon at 13 years. Adjuvant treatment consisted of chemotherapy after the initial diagnosis and hormonal therapy after the relapses. Even though hormonal adjuvant treatment alone was used after ovarian recurrence, the disease-free survival was long (AU)

AIDS-related gastric cryptosporidiosis simulating malignancy

La localización del Cryptosporidium en el estómago es infrecuente. Se presenta el caso de un paciente de 56 años de edad, VIH-positivo, con inmunosupresión severa, después de abandonar el tratamiento anti-retroviral, que presentó malestar epigástrico, náuseas y vómitos. La TC abdominal con contraste mostró un engrosamiento concéntrico importante del antro gástrico. La evaluación endoscópica gastrointestinal reveló falta de distensibilidad de la pared gástrica y marcado engrosamiento, junto con rigidez, distorsión y erosión de los pliegues de la mucosa del antro. El estudio endoscópico fue informado como proceso maligno sugestivo de linfoma. El diagnóstico histopatológico fue de criptosporidiosis. De acuerdo con nuestro conocimiento, la criptosporidiosis gástrica simulando un tumor maligno no ha sido descrita (AU)

Cryptosporidium localization to the stomach is uncommon. We report a case of a 56-year-old, HIV-positive, male patient with severe immunosuppression after antiretroviral treatment dropout who presented with epigastric discomfort, nausea and vomiting. The abdominal CT with contrast showed an important concentric thickening of the gastric antrum wall. Upper gastrointestinal endoscopic evaluation revealed lack of distensibility of the gastric wall and marked thickening, stiffness, distortion, and erosions of mucosal folds involving the antrum region. The endoscopy was clinically reported as gastric malignancy suggestive of lymphoma. The histopathologic diagnosis was cryptosporidiosis. To our knowledge, gastric cryptosporidiosis simulating malignancy has not been previously described. This type of lesion should be included in the differential diagnosis of AIDS patients with lesions simulating gastric malignancy (AU)

Riesgo de enfermedad tuberculosa en pacientes con artritis reumatoide / Tuberculosis risk in patients with rheumatoid arthritis

Antecedentes: Los estudios sobre riesgo de enfermedad tuberculosa (ET) en artritis reumatoide (AR) en pacientes no usuarios de terapia biológica son controversiales. Objetivo: Evaluar AR como factor de riesgo independiente para ET. Diseño: Estudio de cohortes no concurrente. Lugar: Red asistencial Hospital Guillermo Almenara Irigoyen, Lima-Perú, hospital docente. Participantes: Pacientes con AR no usuarios de terapia biológica. Intervenciones: Una cohorte de pacientes con AR no usuarios de terapia biológica (cumplimiento de criterios 1987 del ACR) fue pareada por edad y género con una cohorte control (pacientes con trastornos no inmunológicos). Se realizó una entrevista personal. El seguimiento para la cohorte AR se inició en el diagnostico de AR y culminó en el momento de la entrevista o en el diagnóstico de ET (los controles fueron seguidos el mismo periodo de tiempo). Se calculó la densidad de incidencia (DI) para ET en cada cohorte y el riesgo relativo (RR). La probabilidad de ET de acuerdo al tiempo de enfermedad fue comparada mediante curvas de Kaplan Meier. Se aplicó un modelo de Cox para ajustar drogas y patologías predisponentes (hazard ratio -HR). Principales medidas de resultados: Enfermedad tuberculosa en pacientes con artritis reumatoide. Resultados: La cohorte AR y los controles (667 y 664 pacientes, respectivamente) tuvieron 6 940,75 y 6 666,53 personas-año de seguimiento. La edad al diagnóstico...

Background: Studies on tuberculosis (TB) risk in patients with rheumatoid arthritis (RA) non-users of biological therapy show contradictory results. Objetives: To determine RA as independent risk factor for TB. Design: Non concurrent cohort study. Setting: Guillermo Almenara Asistential Net, Lima-Peru, a teaching hospital. Participants: Biological therapy non-users RA patients. Interventions: RA patients fulfilled the ARA 1987 diagnosis criteria and were biological therapy non-users. Control group was paired by age and sex to RA patients. Patients in control groups had non immunological disorders. Clinical information was completed by interviews. RA patients follow-up was started at the time of diagnosis and ended at the time of interview and/or TB diagnosis. Density incidence (DI) was found for each cohort and TB relative risk (RR) was calculated. To evaluate time length to TB evolution a Kaplan Meier curve was graphed and compared both groups with log-rank test. Drugs and predisposing TB pathologies were analyzed. Main outcome measures: Tuberculosis in patients with rheumatoid arthritis. Results: Six hundred and seventy six out of 808 RA patients and 664 controls qualified for inclusion criteriaÆs. RA and control groups reached 6 940,75 and 6 666,53 follow-up patients-year, respectively. RA cohort mean age was 46,65 at RA diagnosis. Only 29,7 per cent of RA patients had a positive tuberculin reaction. Fifteen TB cases were identified in the RA cohort and 8 at the control group, yielding a mean DI of 216,1/100 000 and 122,1/ 100 000 patients-year respectively. TB RR was 1,8 (IC 95 per cent=0,8- 4,2), and after adjusting drugs and co-morbidity the HR was 1,69 (IC 95 per cent =0,26-10,93). Statistically significant difference was not found with Kaplan Meier curves comparison (p=0,19). Conclusions: We did not find a higher risk of rheumatoid arthritis patients to develop tuberculosis.

[Contrast echocardiography in myocardial perfusion today]. / Estado actual de la ecocardiografía de contraste en la perfusión miocárdica.

Advances in ultrasonic engineering have made possible the development of "intelligent" microparticles with the capacity of passing through the pulmonary circulation in sufficient amount to acquire images of the left heart, making possible the evaluation of myocardial perfusion. Although the Food and Drug Administration of the United States has approved several contrast agents for use in ventricular opacification and visualization of endocardial borders in subjects that have suboptimal studies, at this time, it has not approved any agent of contrast for use in myocardial perfusion. Currently, there are two multicenter studies on a great scale that were exclusively designed for myocardial perfusion in comparison with nuclear medicine and angiography. Our laboratory has had the opportunity to actively participate in both trials. This revision includes the design, interpretation criteria, and preliminary results of CARDIOsphere. As well, we are presenting the interpretation criteria of the AI-700 bubble, which is currently in phase III of clinical investigation. Myocardial perfusion assessment with contrast echocardiography faces several challenges that need to be addressed before it becomes established as an efficient alternative. A common limitation is the viability of this method in subjects with bad acoustic window, the creation of intrinsic artifacts to the system, as distal and lateral attenuation; the unavoidable learning curve, and the settlement of defect quantification criteria.

Estado actual de la ecocardiografía de contraste en la perfusión miocárdica / Contrast echocardiography in myocardial perfusion today

Avances en la ingeniería ultrasónica han llevado a la creación de micropartículas "inteligentes" con capacidad de atravesar en cantidad suficiente la barrera pulmonar transcapilar para permitir la obtención de imágenes de corazón izquierdo, lo que ha hecho posible la evaluación de la perfusión miocárdica. Si bien la Food and Drug Administration de los Estados Unidos ha aprobado varios agentes de contraste para empleo en opacificación ventricular y visualización de bordes endocárdicos en sujetos que tienen estudios subóptimos, no ha aprobado hasta el momento ningún agente de contraste para uso en perfusión miocárdica. En la actualidad existen dos estudios multicéntricos a gran escala que fueron diseñados exclusivamente para perfusión miocárdica en comparación con medicina nuclear y coronariografía. Nuestro laboratorio ha tenido la oportunidad de participar activamente en ambos estudios. Esta revisión incluye el diseño, criterios de interpretación y resultados preliminares de CARDIOsphere. Además, presentamos criterios de interpretación del estudio con la burbuja AI-700 que se encuentra actualmente en fase III de investigación clínica. La ecocardiografía de contraste para perfusión miocárdica enfrenta varios retos que deberá resolver antes de que se establezca como una alternativa eficiente. Una limitante común es la aplicabilidad de este método en sujetos con mala ventana acústica, la creación de artefactos intrínsecos al sistema como son la atenuación distal y lateral, la inevitable curva de aprendizaje, y el establecimiento de criterios en la cuantificación de los defectos.

Advances in ultrasonic engineering have made possible the development of "intelligent" micro-particles with the capacity of passing through the pulmonary circulation in sufficient amount to acquire images of the left heart, making possible the evaluation of myocardial perfusión. Although the Food and Drug Administration of the United States has approved several contrast agents for use in ventricular opacification and visualization of endocardial borders in subjects that have sub-optimal studies, at this time, it has not approved any agent of contrast for use in myocardial perfusión. Currently, there are two multicenter studies on a great scale that were exclusively designed for myocardial perfusión in comparison with nuclear medicine and angiography. Our laboratory has had the opportunity to actively participate in both trials. This revision includes the design, interpretation criteria, and preliminary results of CARDIOsphere. As well, we are presenting the interpretation criteria of the AI-700 bubble, which is currently in phase III of clinical investigation. Myocardial perfusión assessment with contrast echocardiography faces several challenges that need to be addressed before it becomes established as an efficient alternative. A common limitation is the viability of this method in subjects with bad acoustic window, the creation of intrinsic artifacts to the system, as distal and lateral attenuation; the unavoidable learning curve, and the settlement of defect quantification criteria. (Arch Cardiol Mex 2005; 75: 197-209).

Las técnicas de comunicación aplicadas a la entrevista psicosocial / Communication techniques and their application to interviews in social psichology

En este artículo abordamos la entrevista como técnica de búsqueda de información. La entrevista, en tanto método científico de recogida de información, implica unos conocimientos teórico-prácticos sobre las dimensiones psicosociales de la comunicación interpersonal (Valles, 1992). Como técnica de comunicación es una de las más directas en cuanto a relación interpersonal y la más importante dentro de la Intervención Social, pues a través de ella se recoge buena parte de la información que se precisa, esto hace que su dominio sea imprescindible para tales profesionales. La entrevista es una interacción social en donde el entrevistador tenderá normalmente a suponer en el entrevistado unas opiniones y actitudes, similares a las de otras personas del mismo tipo y clase social que el sujeto entrevistado e interpretará así las contestaciones recibidas (Sierra Bravo, 1985)La entrevista es un acercamiento -según Daunais (1984)- muy pertinente en la obtención de datos pues es el método más eficaz y el más económico para obtener la información deseada. La mayoría de los autores señalan que se trata del principal método diagnóstico y en el que se resumen todos los demás. Ebsloeh (1972) apunta que en la perspectiva de la investigación social es un importante instrumento de exploración.

Triplicación de íleon proximal con duplicación esofágica / Triplication of the proximal ileon and esophageal duplication

Las duplicaciones intestinales son anomalías infrecuentes; el sitio de presentación más común es el ileon terminal. Se presenta el caso de un niño con malformación doble de ileon terminal (triplicación) con porción tubular y quística simultánea a una duplicación esofágica. Esta anomalía probablemente no ha sido descrita; y debe ser excepcional. El cuadro se inició con dolor abdominal, sangrado del tubo digestivo y posteriormente abdomen agudo. El diagnóstico se estableció mediante gammagrafía con Tecnecio 99 en el caso de la lesión intestinal; con radiografía de tórax, esofagograma y tomografía axial por computadora de la lesión torácica. Se trataron quirúrgicamente ambas anomalías; la torácica por toracotomía derecha; las lesiones intestinales con laparotomía exploradora y resección del ileon terminal en las partes afectadas